Cycle 1
Health 2024-11-25 · Fire 2024-11-25
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Portland, OR
Mirabella Portland
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3550 S Bond Ave, Portland, OR
(503) 245-4742
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
2011-02-03
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.54
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.68
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.69
CMS adjusted RN staffing hours
Adjusted total hours
5.74
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 7.37% |
| Discharge to community | 45.23% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 43.75% · Lower 95% interval 34.62% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 31.25% |
8.2%
23.1 pts better
|
Numerator 10 · Denominator 32 |
| Staff flu vaccination coverage | 82.76% |
42%
40.8 pts better
|
Numerator 24 · Denominator 29 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.7% |
4.7%
16 pts worse
|
11.4%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 18.2% · 4Q avg 20.7% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.0%
2.4 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.8% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
12.5%
9.9 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
14.7%
9 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.0% |
24.1%
6.9 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
15.8%
15.1 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
1.7%
2.1 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
22.2%
5.3 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 33.3% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.5%
6.5 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
85.4%
10.8 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 97.0% · Q4 97.4% · 4Q avg 96.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
81.2%
13.8 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-02 · Fire 2022-08-02
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-11-25
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-11-25
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-11-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-11-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-14
E · Potential for more than minimal harm
2023-08-24
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-12
E · Potential for more than minimal harm
2022-08-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-09-20
Penalties and ownership
What sits behind the stars
Ownership
Dinan, Linda
Corporate Director · Individual
Grebe, Walter
Corporate Director · Individual
Hawkins, Richard
Corporate Director · Individual
Johnson, Lynn
Corporate Director · Individual
Kortum, Joseph
Corporate Director · Individual
Martin, Charles
Corporate Director · Individual
Mccartney, Sharon
W-2 Managing Employee · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Sabatini, Anthony
Corporate Director · Individual
Sabatini, Anthony
W-2 Managing Employee · Individual
Us Bank National Association
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Reedwood Post Acute
Portland, OR
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Friendship Health Center
Portland, OR
1-star overall rating with 1-star inspections with Special Focus status with $103,564 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Avamere Crestview Of Portland
Portland, OR
1-star overall rating with 1-star inspections with $85,404 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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